Provider Demographics
NPI:1093012908
Name:BULLOCH, MARY (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BULLOCH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21895 CRESCENT PARK SQ
Mailing Address - Street 2:APT 303
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-4434
Mailing Address - Country:US
Mailing Address - Phone:724-433-9242
Mailing Address - Fax:
Practice Address - Street 1:21895 CRESCENT PARK SQ
Practice Address - Street 2:APT 303
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-4434
Practice Address - Country:US
Practice Address - Phone:724-433-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-12
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist